IRIN editors give their weekly take on humanitarian news, trends, and developments from around the globe.

On our radar

Trouble at the top

The overall coordination body for humanitarian aid lacks a vision, mission, strategy, and sound funding, according to a UN audit. The Inter-Agency Standing Committee, or IASC, formed in 1991, brings together the UN agencies, the Red Cross/Red Crescent Movement, and NGOs in a humanitarian über-cabinet. It is chaired by the head of the UN Office for the Coordination of Humanitarian Affairs, Mark Lowcock. His office says he has been working to sort out the group since the period of the audit (2016 to mid-2017). A well-placed senior aid official, who asked for anonymity due to the sensitivities, said the committee was making progress on a few issues, such as preventing sexual abuse. The audit revealed problems found in confidential reviews in 2003 and 2014 persisted, notably “insufficient commitment to collective leadership”. The official said there is a “fundamental problem”: if members don’t have stronger incentives to cooperate, further attention to the IASC’s structure "is going to be tinkering at the edges".

Strange bedfellows: mining firms and humanitarians?

In February, a magnitude-7.5 earthquake rattled Papua New Guinea’s remote highlands region, toppling villages, killing dozens, and leaving some 270,000 in need of help. Aid groups requested $62 million to respond. International donors have pitched in, but the largest contribution – equivalent to nearly two thirds of the appeal – came from the private sector, including the mining, oil, and gas industries. A briefing released this week by the Melbourne-based Humanitarian Advisory Group explores how extractives companies responded. It’s a polarising issue for many in the aid sector: some organisations, researchers note, refuse to work with or accept money from extractives companies, which have been accused of causing environmental damage and “serious human rights problems” in the past. The HAG briefing notes that extractives companies often responded faster than aid groups after this year’s earthquake, and used their logistics resources to access remote areas blocked by the damage. But they also lacked formal training on humanitarian practices and principles: some aid workers thought companies were targeting only communities in their business areas, for example; others said companies dumped supplies without monitoring to ensure they actually reached their intended targets. Despite the problems, the researchers conclude there is “enormous potential” for engaging extractives companies in disaster response in the Pacific.

Concerns around aid operations in South Sudan

Médecins Sans Frontières is concerned its operations in South Sudan may be at risk due to revelations it made about mass rapes in the town of Bentiu in November. This week officials from the medical NGO said the report that at least 125 women and girls were raped by armed men – some in military uniform – had caused friction. “The government of South Sudan is not happy,” an MSF official was anonymously quoted as saying by Kenyan newspaper The East African. “So who knows, maybe our massive operations in Bentiu will come to a close and place at a risk thousands of lives.” The UN condemned the attacks, sent a team of human rights investigators to Bentiu, and called for the culprits to face justice. Human Rights Watch also called for an urgent investigation into the violence. Under pressure, the South Sudanese government sent an investigation team to Bentiu, but this week it claimed there was a “lack of evidence” to substantiate the rape allegations.

Healthcare boost for Yazidis in Iraq’s Sinjar

Some good news for a change. You may recall a series of three stories we did back in March and April on the Yazidis in Iraq’s Sinjar province, where the religious minority fled massacres and enslavement by so-called Islamic State in 2014. Reporter Tom Westcott found that tens of thousands of families had been returning to towns and villages once ruled by IS, only to face a healthcare crisis. In the bullet-ridden hospital of Sinjar town itself, one doctor with no ambulance was struggling to meet the needs of the many returnees. Today, the situation is greatly improved, Westcott reports. The hospital has moved to new and better premises, has several ambulances, and is being assisted by NGOs. In a visit on 15 December, Nadia Murad said she planned to use her $1 million Nobel Peace Prize money to build another hospital in Sinjar, her hometown.

In case you missed it:

AFGHANISTAN/SYRIA: President Donald Trump ordered a full US withdrawal from Syria and the drawdown of about half the 14,000 remaining American troops in Afghanistan. Critics rounded on both decisions as premature, with particular concern raised over the possibility of a new humanitarian disaster if the situation unravels in northern Syria. US Defence Secretary James Mattis announced his resignation on the back of the moves.

THE DEMOCRATIC REPUBLIC OF CONGO: Elections to replace President Joseph Kabila were postponed yet again this week, following a previous delay of more than two years. The country is on the cusp of its first ever democratic transfer of power, but a host of humanitarian crises – from Ebola to protracted conflicts – awaits the next leader.

MADAGASCAR: The leading candidates in Madagascar’s election – both former presidents – have each claimed victory in this week’s polls. Marc Ravalomanana, who came to power in 2002, is up against Andry Rajoelina, who ousted him in a military coup in 2009. Rajoelina then ruled for five years until he was forced out in protests led by Ravalomanana. Official results are due next week. Nine in 10 of Madagascar’s 25 million population live on less than $2 a day, and the island faces huge health and malnutrition problems, made worse by drought and devastating El Niños.

MYANMAR:Clashes between Myanmar soldiers and the Arakan Army, an armed group that advocates for the ethnic Rakhine community, have displaced hundreds of civilians this month in western Myanmar.

Weekend read

Latest UN estimates put the number of people forced from their homes by conflict between Cameroon’s anglophone minority and the francophone-majority state at 437,500. Many have taken to hiding in the bush, including tens of thousands of school-age children. An untold number are missing out on an education as the insurgency escalates, school attacks and kidnappings spike, and separatist fighters demand schools stay closed. Our weekend read includes interviews with parents, officials, and kidnapped children, and explores how education was the starting point for this crisis, and how a generation of children now risks being recruited by armed groups and perpetuating the conflict.

And finally…

A vaccine with wings

This week in a remote corner of the Pacific Island nation of Vanuatu, a commercial drone buzzed 40 kilometres above rocky terrain to deliver an important payload: vaccines to immunise 18 people, including a one-month-old child. It could be an early step toward Vanuatu’s health ministry integrating drone technology into its immunisation programme, which is challenged by scattered communities and inaccessible terrain. According to UNICEF, only one third of Vanuatu’s populated islands have airfields or roads, and one in five children in remote areas don’t have access to vaccines. Aid groups and health agencies have been testing humanitarian uses for drones for years. A US company uses drones to deliver medical supplies in Rwanda; humanitarians have explored using drones for post-disaster mapping; a non-profit in Fiji is trialling drones to unleash a swarm of dengue-fighting mosquitoes. In Vanuatu, proponents of the ongoing vaccine delivery trials say this week’s successful handoff is a ”big leap for global health”.

To our readers: This is the last Cheat Sheet of 2018. We’ll be back on 11 January, but watch for special Friday coverage during the next two weeks. Best wishes for a brighter 2019.

IRIN editors give their weekly take on humanitarian news, trends, and developments from around the globe.

On our radar

Respite for Yemen’s Hodeidah

It’s been a busy week for Yemen, at least in the realms of diplomacy and foreign politics. After a week of peace talks in Sweden, on Thursday the UN announced the warring sides had agreed to a ceasefire in the key port city of Hodeidah and the wider province of the same name. Their fighters are to withdraw the city within 21 days, and UN Secretary-General António Guterres said the “UN will play a leading role in the port”. We’ll be keeping a close eye on this deal and what it means for civilians; you can read the fine print here. Later on Thursday, the US Senate voted to withdraw support for the Saudi Arabia-led coalition fighting in Yemen. It was a rebuke to President Donald Trump’s backing for the kingdom’s crown prince despite mounting evidence of his involvement in the killing of a dissident Saudi journalist, but a largely symbolic one, as Trump has vowed to veto the measure if it passes the House of Representatives and reaches his desk.

Challenges as Congo prepares to replace Kabila

The Democratic Republic of Congo's long-delayed presidential election is now just over a week away. But it's still far from smooth sailing, as thousands of voting machines were destroyed in a warehouse fire in the capital, Kinshasa, this week. Officials said the blaze seemed to be criminal in nature, but gave assurances it would not affect the poll. Use of the machines, a first in Congo, have raised opposition concerns of possible voter manipulation in favour of ruling party candidate Emmanuel Ramazani Shadary, who was chosen by President Joseph Kabila as his preferred successor. Kabila, who has been in power since 2001, won’t stand for re-election on 23 December, but said he may contest the 2023 poll. The EU meanwhile renewed sanctions on leading Congolese politicians, including Shadary, saying they were open to reviewing the decision after the election. Kabila, however, has refused to accredit EU election observers, calling the sanctions “politically motivated” and promising to retaliate. One to watch.

Linking climate change and extreme weather

Heatwaves in China and the Mediterranean; drought in East Africa and the United States, heavy flooding from parts of Asia to South America: all of these weather extremes that struck across the globe in 2017 would have been “virtually impossible” without the impacts of climate change, according to new research released this week. The study, published in the Bulletin of the American Meteorological Society, is part of the growing body of “attribution science”, which explores the links between climate change and extreme weather events. The AMS says 70 percent of its research on the topic has found a “substantial link” between extreme events and climate change. There’s a growing push among vulnerable nations to be compensated for loss and damages from climate-linked disasters, but it’s among the more sensitive topics in global climate negotiations – including the COP24 summit set to conclude 14 December in Poland. While countries debate a path forward, communities on the front lines of climate change are already struggling to adjust. Read more on what coping with climate change means for people already living with its impacts.

Gas guzzlers put on notice

Humanitarian organisations are large-scale polluters, don't have renewable energy strategies and waste $517 million a year on fuel costs. Those are some of the blunt messages of a new report published by think tank Chatham House. It finds that although it makes up about five percent of spending, fuel use is not closely tracked and there are few incentives to be more efficient. The study surveyed 21 aid operations in Burkina Faso, Kenya, and Jordan. In Kenya, partly because of heavy generator usage in remote locations, seven agencies were found to spend $6.7 million a year on fuel and related maintenance. There are some exceptions: solar systems for refugee camps in Jordan save $7.5 million a year; adding solar and wind power at a single WFP store in Afghanistan should save $60,000 a year. Donors could push for higher standards by demanding data on emissions, efficiency, and usage, the report argues.

In case you missed it

Ebola: Frontline health workers in South Sudan will begin receiving vaccinations for Ebola next week, the WHO said, as the country faces “very high risk” from an outbreak that's killed more than 300 people in neighbouring Congo. Ebola has not spread beyond Congo, but as a precaution, vaccinations also began in Uganda last month.

Papua New Guinea: Powerful volcanic eruptions on Manam Island, off Papua New Guinea’s northern coast, have triggered lava flows and ash fall and displaced multiple villages. A previous eruption in August destroyed two villages, while eruptions in 2004 forced the entire island to evacuate.

ThePhilippines: The Philippine Congress this week extended martial law on the southern island of Mindanao through December 2019 – drawing criticism from rights groups. Parts of the island are preparing for a January plebiscite that could create a new autonomous region comprising majority-Muslim areas.

Syria: UNICEF said that two sick babies died in the past week at Rukban, an isolated camp where 45,000 Syrians are trapped between the Jordanian border and Syrian government front lines. A convoy delivered supplies to the area in November. Before that civilians had gone with almost no aid since January. Meanwhile, the UN Security Council extended authorisation for cross-border aid deliveries elsewhere.

Weekend read

The statistics speak for themselves: an estimated 400,000 dead, 4.5 million displaced, seven million said to be in need of aid. As South Sudan marks five years of war on 15 December, there is no question that the conflict has exacted an enormous human cost. Our weekend read curates our recent coverage along with a new slideshow and updated timeline of the conflict. As the war enters its sixth year on Sunday only the most optimistic of observers is voicing much hope that the revitalised peace agreement, signed in September by President Salva Kiir and his former rival and soon-to-be vice president (again) Riek Machar, will hold for very long. Regardless, it hasn’t brought an end to the violence, the hunger, and the need for broad-based reconciliation. Look out too for South Sudan analyst Alan Boswell’s stark assessment of where things stand heading into 2019.

And finally...

The axis of helpful

Indonesia, take a bow. A new survey, The World’s Most Generous Countries Report, finds that Indonesians are the most charitable nationality. 153,000 interviewees in 146 countries were asked by pollster Gallup if they a) donated money, b) volunteered their time, or c) helped a stranger. Extrapolating the numbers, Gallup suggests 2.2 billion people helped a stranger in 2017 (about 43 percent of the world's adults). Glass half full: good neighbourliness is alive and well. Glass half empty: what is wrong with the other half? Gallup combines the results into a score per country. Australia, New Zealand, Ireland, and the United States make up the rest of the top four. The bottom scorers for "civic engagement" are China, Greece, and Yemen. Does that seem fair?

(TOP PHOTO: A woman who fled fighting in Hodeidah arrives at an informal shelter in Aden, Yemen. CREDIT: Ammar Bamatraf/UNHCR)

It has been exactly half a decade since armed men stormed Matok Kuol’s home and murdered his family. The images of their bullet-riddled bodies remain singed in his memory.

“I’m not okay in my head,” explained Kuol, 23, speaking at the UN-run displacement camp in South Sudan’s capital, Juba, where he now lives. “I’m always stressed.”

What began on 15 December 2013 as a political power struggle between President Salva Kiir, his former deputy Riek Machar, and other opposition groups, quickly escalated along ethnic lines. Conflict has proliferated across South Sudan over the past five years, leaving almost 400,000 people dead, displacing millions, and plunging pockets of the nation into famine.

While politicians say they are now committed to a new peace deal signed in September, some people in South Sudan have started finding ways to rebuild their lives and a few have begun returning home. But many remain sceptical, especially since violence continues.

When Kuol first came to Juba in April 2011, just a few months before South Sudan gained independence from Sudan, he had hopes of belonging to a “good country, like others around the world”. He was studying to become a pharmacist and planned to move to Uganda to attend university. During his five years in the UN camp, unable to afford the fees, even the uniform, he hasn’t been to class once.

Since clashes began, South Sudan now has the world’s highest proportion of children out of school, a USAID official told IRIN. At least 2.2 million children aren’t getting an education, according to UNESCO, up from 1.7 million in 2013.

By early 2019 almost 50 percent of the country, more than five million people, are expected to face severe food insecurity and 36,000 will be on the brink of starvation, according to the latest analysis by the government and the UN.

The country’s leaders and politicians are roundly blamed for the conflict, and for its far-reaching effects.

“They have triggered a senseless and man-made war, which has created negative implications for innocent civilians,” said Edmund Yakani, executive director for the Community Empowerment for Progress Organisation, a local advocacy group.

Yakani said the mass rape of women and girls, extra-judicial killings by “unknown gunmen”, and roadside ambushes have all terrorised civilians, without the perpetrators being held to account.

Five years of violence

Since the start of the conflict, almost two million people have been internally displaced, while more than two million others live as refugees in neighbouring countries. Almost 200,000 people are sheltering in six UN sites across the nation. Kuol is one of 32,000 people living in squalid conditions in the camp in Juba, too terrified to return home for fear of being killed.

Months after the peace deal was signed, progress is stifled by continued delays, missed deadlines, and ceasefire violations. The UN and aid groups said 150 women and girls were raped and beaten within a 10-day period at the end of November while walking to a food distribution site outside the town of Bentiu in Unity State. In a report released last month, a UN Panel of Experts expressed concern about “alarming” levels of sexual assault, compounded by a desperate humanitarian situation.

While the official ceasefire monitoring body has noted a significant decrease in fighting across the country since September, pockets of violence continue, particularly in Yei in central Equatoria State, in the northeast region of Wau, and in Unity State, where tensions remain high.

There has been a strong push to bring commanders of the warring sides together to build trust and prepare the government and opposition armies to unite as one, as stipulated in the agreement.

Last month, division commanders in Wau met for the first time since 2013 in an attempt at reconciliation. Government programmes are also slated to start in the new year to train fighters and redeploy them throughout the country, according to one opposition official, who wasn’t authorised to speak on the record.

While top commanders on both sides say they are committed to the peace process, a source familiar with the implementation of the accord told IRIN that fighters on the ground aren’t always aware of the ceasefire, especially those who are deep in the bush and don’t have easy access to information. The source said a lack of command and control within armed groups could allow violence to continue across the country.

The UN’s head of office in Wau, Sam Muhumure, told IRIN in November that civilians had recently been abducted about 50 kilometres outside the city and neither the government nor opposition took responsibility. David Shearer, the UN mission chief in South Sudan, said it’s also still possible that children across the country are being recruited into armed forces.

“It’s damaged our social fabric”

Civil society groups say there’s a big disconnect between the national and grassroots peace processes.

After speaking with local community leaders around the country, Aluel Atem, co-founder of Crown the Woman South Sudan, a local NGO dedicated to promoting gender equality and sustainable peace, said it was clear they had no idea what the agreement entailed, largely because of poor communication and a lack of engagement by politicians in Juba.

Atem, who grew up in exile in Uganda, said the most painful part of the last five years has been her loss of identity.

Recalling that her university transcript was inscribed with the letter ‘X’ under citizenship because officials didn’t know what to write, she said South Sudan’s independence in 2011 made her feel as if she finally belonged: “No more refugee status, no more running away”.

But everything changed in 2013 and now she feels her nationality is something she needs to “hide from”.

Atem said travel has become exhausting, with regional border agents stamping her passport and constantly asking: “Why are you South Sudanese killing each other?”

As a Dinka – the same ethnic group President Kiir belongs to – Atem says she no longer feels safe moving around the country, even declining work opportunities because of security concerns.

“The aspect of tribalism… and that [Dinka] identity has been branded as the identity of the ruling government, the top leadership destroying the country, makes me feel sometimes if I go to Western Equatoria it's not easy for me," Atem explained. “[The war has] damaged our social fabric, and I think it’s going to take another century to rebuild and proudly identify as one people.”

Pete Martell, a long-time observer, journalist, and writer on South Sudan, agreed. Regardless of the “paper deals and political struggles at the top”, building genuine peace that resonates on the ground will take a long time, he said. “There are tough, tough times ahead.”

Matok Kuol in the community centre in the UN-run displacement camp in Juba.

Crossing the divide

While the conflict has dissuaded many South Sudanese living abroad from returning, for one woman it was the catalyst that pushed her in the other direction.

Robecca Nyakeir Thor, a dual South Sudanese and US national, grew up in a tight-knit South Sudanese community in America’s Midwest. When clashes broke out in 2013, splitting South Sudan along ethnic lines, similar social divisions emerged abroad, said Thor, herself a Nuer, Machar’s ethnic group.

She wanted to change the narrative, so she started working in conflict resolution before eventually relocating to South Sudan, where she became private secretary for Machar. “It was less about the ideology at first, but after I began to align myself with why I was there, came the justice and the push and pull of a revolution,” she said.

Thor worked with Machar throughout his transition to Juba in April 2016, where the rebel leader resumed his position as First Vice President. When renewed clashes broke out in July that year and forced him to flee, she remained, eventually taking a job with the government. Today, she serves as private secretary for First Vice President Taban Deng Gai, and is part of the group charged with implementing the new peace deal.

Some called her a traitor for joining the government instead of sticking with the opposition, but Thor says her actions have always been about peace. If people keep pushing the government and politicians hard enough, she said, things will change.

Remnants of 2015’s failed peace attempt linger, however, even as efforts to put the current agreement in place get under way. Scepticism runs deep, especially in opposition-held territories where those who fled recent fighting by government soldiers told IRIN in August that they won’t be convinced there’s peace until the army leaves their towns.

And some aid groups are concerned that too much optimism around the deal will negatively impact civilians, particularly if they decide to leave the UN camps prematurely. A report released last week by Refugees International warned that “rushed returns risk fueling ethnic tensions and costing lives”.

So far, those living in the camps aren’t convinced it’s time to go home.

In Juba, Kuol says his room-mate left the UN site at the end of October, only to be dragged into a hut and beaten by government soldiers, who sent him back to the camp with a message for its inhabitants: if you come out, you’ll suffer the same fate.

Leaning back in his chair, Kuol recalled his life before the war and imagined what it might be like when he is able to leave. “If I wasn’t in here, I’d be in school, I’d be working,” he said. “I’d be free.”

(TOP PHOTO: A group in the community centre in the UN-run displacement camp in Juba. CREDIT: Sam Mednick/IRIN)

Treating undernourished children, boosting nutrition for pregnant women, and even providing a statistical basis for the term “famine” have all become routine parts of humanitarian health programmes. But the routine is changing.

As conflicts and crises overtake middle-income countries like Syria and now Venezuela, aid organisations must deal with obesity and non-communicable diseases (NCDs) such as diabetes, heart disease, and high blood pressure.

In 2017, the World Health Organisation for the first time added medication for diabetes to its standard Interagency Emergency Health Kit – a package of supplies and pharmaceuticals that can meet the needs of 10,000 people over three months. In October that year, in Syria and Iraq, it also started testing a supplementary kit containing medication for non-communicable diseases.

“It was the first time that such a need was recognised,” said Amulya Reddy, a medical advisor at Médecins Sans Frontières, speaking of the Syrian refugee crisis. Before the Syria crisis, she said, “treating NCDs wasn’t part of the routine emergency actions. It was considered more of a medical speciality – most organisations had no experience.”

In more than half of Syrian refugee households in Lebanon, for example, at least one person was diagnosed with at least one of five NCDs in 2016 – three of which (hypertension, cardiovascular diseases, and diabetes) are diet-related.

Yet steps toward treating chronic diseases among these newer groups of refugees have not kept up with the growing need. Added to that, development and humanitarian organisations face data and funding stumbling blocks as they rethink ways to work together to combat non-communicable diseases.

“NCDs have been neglected so far, but the situation is becoming dire. We will need to adapt to the new challenges – and fast,” warned Slim Slama, a medical officer for NCDs for the Eastern Mediterranean region at the WHO. “Most of the humanitarian system has been geared towards the acute conditions.”

New international guidelines offer a roadmap to humanitarian organisations dealing with such conditions. The Sphere Handbook, a compilation of standards in relief work released last month, includes more detail on NCDs than its previous 2011 edition.

It states, for example, that a patient should not miss medication for non-communicable diseases more than four days a month. The Ebola epidemic and “Syria changed everything in terms of how we frame humanitarian response,” Christine Knudsen, Sphere director, told IRIN.

In addition, the 2018 Global Nutrition Report, released last month, says the issue of diet-related chronic conditions has “barely been on the radar of those responsible for responding to crises until recently.” The study is commissioned by a group of international NGOs, drawing inputs from members of governments, civil society, academia, multilateral organisations, and private businesses.

Different incomes, different problems

In low-income countries, more than half the adults are most likely to die from communicable diseases, conditions arising during pregnancy and childbirth, and nutritional deficiencies. In middle-income countries, the pattern changes, with higher numbers of deaths due to obesity and NCDs linked to a more affluent but unhealthy diet and lifestyle.

The upper and middle classes of poor countries, too, are more likely to suffer from chronic conditions. In terms of absolute numbers, the WHO estimates that 78 percent of global deaths from NCDs took place in low- and middle-income countries. In addition, rising obesity in poorer countries is a sign of risk for non-communicable diseases. A recent life expectancy forecast published by a British medical journal, The Lancet, stated that NCDs as cause of premature mortality will double by 2040.

Screening for and treating diseases such as diabetes, heart disease, and high blood pressure has become central to MSF’s operations in Jordan, Reddy said. “It became obvious very quickly that the majority of the refugees had NCDs, and those would need to be addressed.”

The Lebanese example

Hala Ghattas, an associate research professor at the Center for Research on Population and Health at the American University in Beirut, who contributed to the Global Nutrition Report, said there is a need to move beyond traditional response, especially as “humanitarian crises are increasingly occurring in middle-income and low-income countries that are going through demographic and epidemiological transitions”.

In the report, Ghattas and her colleagues analysed how humanitarian agencies addressed various NCDs among Palestinian and Syrian refugees in Lebanon.

They found, for instance, that the Lebanese Ministry of Public Health and the UN’s refugee agency, UNHCR, worked together to respond to the high incidence of NCDs among Syrian refugees by providing subsidised care in the primary healthcare system as well as a referral system for secondary and tertiary care. This meant that 75 percent of the refugees’ treatment costs were covered.

Their research showed that 34 percent of the Syrian refugee population aged 18 to 69 years are overweight, 29 percent are obese, and 49 percent have elevated total cholesterol levels. In related research, the International Committee of the Red Cross has reported that diabetes is the cause of more than 25 percent of amputations in one third of their centres in the Balkans, Iraq, Lebanon, Liberia, Pakistan, South Sudan, Syria, and Yemen.

And yet, progress has been slow.

The United Nations General Assembly passed a political declaration on NCDs in September, but it fell short of extending guidelines for crisis situations. “For the first time, there was a reference to disasters, which is a good step, but there was no reference to NCDs in conflict situations,” said Slama.

The way forward

As they try to adapt, health workers are increasingly borrowing lessons learned by the medical and emergency communities during the HIV epidemic in conflict-affected countries like Rwanda and the Central African Republic.

“We’ll have to work towards simplifications in the process, decentralise programmes, and make them more community-based,” Reddy said, adding that data collection on the rates of NCDs among populations in crisis situations is “consistently difficult”.

A lot of the initial work by humanitarian responders in crisis situations is geared towards meeting basic needs and focusing on the most vulnerable in any group. In Lebanon, for example, Ghattas said it took time for the data to catch up with the services. The first survey on NCDs was conducted in 2014, after emergency responders had started caring for those with urgent needs.

“Systems are still ill-equipped to handle NCDs, and as a result there is little evidence on what works and what doesn’t,” Slama of WHO said. As more evaluation results are gathered and new research emerges, medical practitioners will be able to tweak their approaches and tailor them to specific contexts.

For Slama, one of the biggest challenges will be to train medical staff. “We should measure the impact not just in terms of distribution but also provision of care. It is important to look at service utilisation, and to see if people are getting the services they need,” he said.

According to Ghattas, increasing talk of the “humanitarian-development nexus” – a new catchphrase in aid circles that underlines the need to join up emergency and longer-term responses – might be a good sign for the recognition of NCDs in crises.

Some experts are hopeful this trend will result in higher funding for cross-cutting programmes. Currently, the most optimistic estimates put the share of NCDs in global Overseas Development Assistance at two percent, making it a blind spot in the larger global health community. “So, not surprisingly, when conflicts occur and systems collapse, NCDs amongst affected people are ignored,” said Slama.

In a time of increasingly dwindling resources and competing needs, raising funds for NCDs is a tough battle. Or, as Reddy put it: “Unfortunately, NCDs don’t bring in money from donors in conflict situations; starving children do.”

IRIN editors give their weekly take on humanitarian news, trends, and developments from around the globe.

On our radar

"Brutal attacks" against women and girls in South Sudan

Despite some cautious optimism around a new peace agreement, civilians are still far from safe in South Sudan. Aid groups say more than 150 women and girls were raped, beaten, and brutalised over a 10-day period at the end of November. Armed men, many in uniform, carried out the “abhorrent” attacks near the city of Bentiu, the UN said. Médecins Sans Frontières, which provided emergency medical care to survivors, expressed deep concerns. “Some are girls under 10 years old and others are women older than 65. Even pregnant women have not been spared from these brutal attacks,” said MSF midwife Ruth Okello. Since the war began in 2013, South Sudan has seen horrific levels of sexual violence. In the first half of 2018, 2,300 cases were reported; more than 20 percent of victims were children, the UN said. For more on the conflict and what it’s like to live in Juba and report on it, watch this frank Q&A interview with IRIN contributor Stefanie Glinski. And look out for our special package next week as the war marks its five-year milestone.

UN accused of manipulating data in Congo

Aid groups working in the Democratic Republic of Congo have accused the UN of "manipulating" data and bowing to government pressure ahead of elections later this month. In a statement in November, the UN’s emergency aid coordination body, OCHA, put the overall number of people needing assistance in Congo in 2019 at 12.8 million, a slight decrease on last year, despite the fact that according to the authoritative IPC scale 13.1 million Congolese are facing crisis or emergency levels of food insecurity next year (up from 7.7 million in 2018). The OCHA overall needs figure appears to only count the displaced as 1.37 million people newly displaced between January and August 2018. Aid groups say that overlooking three million people who had already been displaced prior to that will dramatically impact their ability to respond to needs, and may encourage forced closures of IDP camps. A letter obtained by IRIN – addressed to UN aid chief Mark Lowcock and Kim Bolduc, the UN’s most senior humanitarian official in Congo – from a forum of 45 international NGOs working in the country, blames the decision on "increased politicisation of humanitarian data", which they say sends a misleading message that the situation is improving "despite clear evidence to the contrary". OCHA has denied manipulating data. Read our report from April on how relations were already strained between aid groups and the Congolese government, after it failed to attend its own donor conference in March.

UNAIDS: "A broken organisational culture"

An independent report on harassment and management culture at the UN's specialised HIV/AIDS body, UNAIDS, is out today and it's damning. The executive director, Michel Sidibé, is found to have set up a "patriarchal culture", and the organisation to be in crisis. The four-month review followed reports that a senior UNAIDS official's sexual misconduct was not properly handled. The report plants the blame at the feet of Sidibé. He has been "tolerating harassment and abuse of authority" and "accepted no responsibility for actions and effects of decisions and practices creating the conditions that led to this review,” it said. In an email to staff, Sidibé wrote: "I have taken on board the criticisms."

Disputed Papua killings raise tensions in Indonesia

Violence this week in the Papua region put the spotlight back on a decades-long pro-independence movement along Indonesia’s eastern edge. Indonesian authorities say pro-independence fighters killed up to 31 people working on a controversial infrastructure project in Papua province this week, though an armed group that reportedly claimed responsibility said those killed were not civilians. A separate pro-independence leader called for restraint and warned of retaliatory attacks by Indonesia’s military. For decades, Indonesia has quashed Papuan nationalism, which includes both armed elements and a peaceful movement by activists who have called for a referendum on independence. Over that time, the heavily militarised region has been mired in poverty and under-development, letting treatable health problems fester. Earlier this year, a measles outbreak killed dozens of children.

One year after victory, is Iraq IS-free?

One year ago (on 9 December, to be exact) Iraq declared victory against so-called Islamic State. The country’s recovery has come in fits and starts. There were elections and a new prime minister, but he’s not yet managed to form a government. November saw the lowest number of civilian deaths and injuries in violence, terrorism, and armed conflict in six years, but a new report from the Center for Strategic and International Studies says IS is regrouping, operating in a cell structure, and targeting the Iraqi government, especially local village heads. And while 4.1 million Iraqis who fled their homes during the IS years have returned home, 1.9 remain displaced, half of them for more than three years. The UN says it’s increasingly clear many of these people don’t want to (or can’t) go home, many still rely on aid, and it’s not clear what their future holds.

Plus ça change

MSF employs more people than any other relief organisation, and there are 570,000 people working in humanitarian aid overall. Just two new data points from an ambitious report, the State of the Humanitarian System 2018, released this week. The study finds that the global political climate is causing a "decline in performance in the areas of coverage (the ability to reach everyone in need) and coherence (the ability to conduct operations in line with international humanitarian and refugee law)". The report, from the Active Learning Network for Accountability and Performance, or ALNAP, also gives a lukewarm appraisal of the humanitarian system: “incremental improvement in some areas, and a lack of movement in others”. While UN agencies dominate the funding picture, six large NGOs command 23 percent of the spending in 2017, the report finds. The 331 page report came hard on the heels of the UN-led omnibus humanitarian appeal for 2019, which signalled the need for $25 billion in aid for more than 90 million people.

In case you missed it

Afghanistan: Two bodies managing October parliamentary elections are clashing over poll results in the capital, Kabul. The elections complaints commission declared fraud and invalidated all votes cast in Kabul, but the agency overseeing the vote said it would ignore the ruling.

China: More than 7,400 women and girls could be victims of forced marriage in just a few remote districts along the northern Myanmar-China border, according to a new study. Nearly 40 percent of women interviewed for the research said they’d been forced to marry.

Ebola: Eighteen new Ebola cases and five more deaths have been recorded in just two days in Congo. The health ministry expressed particular concern about the spread in Butembo, a major trading city in North Kivu province. With 471 cases, including 273 deaths, the outbreak is now the second-largest ever.

Libya: Locals say a US strike in Libya killed as many as 11 civilians at the end of November, the casualty monitor Airwars reports. The US says the strike targeted a local faction of al-Qaeda.

Mediterranean: MSF and SOS Méditerranée say they have been “forced” to stop operating their Aquarius migrant rescue vessel. The ship, which has saved countless lives in the Mediterranean since 2015, has been docked in Marseilles since Panama revoked its registration in September after sustained legal pressure, in particular from Italy.

Yemen: Two sides in the war kicked off talks in Sweden on Thursday, as a new report said that 20 million people back in Yemen are hungry, including nearly a quarter of a million who could soon be on the “brink of death”, but the threshold for famine has not been met.

Our weekend read

“Yes, the babies die”: Tales of despair and dismay from Venezuela

To get a sense of how fast and how far Venezuela has fallen, look no further than the University Hospital of Maracaibo. Once a shining beacon of the South American nation’s oil-rich economy, this modernist building that once pioneered liver transplants now peels into disrepair and lacks electricity, water, even basic medicines. Inside, the shelves lie empty, coated with flies. Outside, a large mound of blue rubbish bags grows, rotting, by the day. “Hospitals have become like extermination camps,” says surgeon and professor Dr. Dora Colomenares. Our weekend read is the latest instalment of Susan Schulman’s special report on the humanitarian impacts of Venezuela’s economic collapse. Through the graphic accounts of patients and doctors, it lays bare the collapse of a healthcare system that has lost most of its capability to treat the sick. As more and more medical personnel join the mass exodus from the country, malnutrition is weakening immune systems and long-dormant diseases are returning. “We feel very helpless because there is nothing we can do,” Colomenares says. “Yes,” she nods, “yes, the babies die.”

And finally…

The muppets are coming to the Rohingya refugee camps. The Lego Foundation this week announced a $100 million grant to the Sesame Workshop – the non-profit behind the long-running US children’s TV show. The money will be used to bring “play-based early childhood development” targeted to Rohingya and Syrian refugee children, including a curriculum featuring Sesame Street’s fuzzy muppet puppets (yes, they are muppets). In Bangladesh, this will include partnering with the Bangladeshi NGO BRAC, whose work in the camps includes running “learning centres” for children – Bangladesh’s government does not allow formal schooling for Rohingya refugees. In case you’re wondering, there is indeed a Bangladeshi version of Sesame Street, and the proponents of this initiative say it will be a part of the programming.

(TOP PHOTO: South Sudanese students at an event for the International Day for eliminating Sexual Violence in Conflict. CREDIT: UNMISS)

As talks opened in Sweden today aimed at setting a framework to eventually end Yemen’s 44 months of war, a new report stopped short of declaring famine but said that 20 million Yemenis are hungry and need food aid.

Lise Grande, the UN’s top humanitarian official in Yemen, told IRIN that the Integrated Phase Classification (IPC) report found that of the 20 million, 238,000 people “are barely surviving. Any small change in their circumstances, any disruption in their ability to access food on a regular basis, will bring them to the brink of death.”

Grande said these people are mostly in four provinces where “conflict is raging”: Taiz, Sadaa, Hajjah, and Hodeidah.

Since March 2015, Yemen’s war has pitted Houthi rebels and their allies against the internationally recognised (but exiled) President Abd Rabbu Mansour Hadi, backed by a Saudi Arabia-led coalition.

Their fight has had devastating consequences for civilians. Asking for a record $4 billion for humanitarian assistance next year, the UN said this week that 24 million people, some 80 percent of the population, are in need of assistance.

“As parties to the conflict in Yemen sit down at the table this week, we urge them to look as closely as we do at the humanitarian implications of this war,” read a statement from Mohamed Abdi, Yemen country director for the Norwegian Refugee Council.

Here are a few of those implications for the millions of Yemenis stuck in the war – still being waged some 5,000 kilometres away from the castle outside Stockholm where the warring parties are gathered to hash it out.

20 million hungry

Despite recent warnings of famine from UN officials (UN aid chief Mark Lowcock said in late October that there was danger of a “great big famine engulfing” Yemen), not to mention some increased media coverage of the country featuring striking pictures of emaciated children, the IPC report means an official declaration of famine is not imminent.

That doesn’t mean people aren’t going hungry or dying because they don’t have enough to eat: the threshold for declaring famine is high, and requires an amount and quality of data that may not be collectable in Yemen. In past famines, many deaths have happened before a proclamation was made.

The IPC’s scientific methodology is intended to separate the process of declaring famine from politics by implementing uniform measures across countries. It uses a five-point scale to measure food insecurity, and Grande said 152 of Yemen’s 333 administrative districts are now classified as level 4 emergencies, adding: “this means that close to half of all districts in the country are one step away from catastrophe.”

While the results of the IPC survey were presented to UN agencies and NGOs Thursday, the report itself has not yet been released. Several UN sources said it was delayed because of confusion in the implementation of new IPC protocols, but a senior food security expert following the situation said he was “baffled why they are not releasing the report”.

7,000 – 57,000 dead

While various numbers are floating around, we simply don’t know how many people have died as a result of Yemen’s war, be it from hunger, bombs, bullets, or disease.

The UN’s human rights office keeps statistics on the number of civilians who have been killed and injured in violence and, as of today, they count 6,906 killed and 10,861 injured since the end of March 2015. The UN says these figures are a “conservative estimate”, given their strict requirements for verification and access constraints in some parts Yemen.

ACLED, which collects data on political violence and utilises numbers from the Yemen Data Project, estimates that more than 57,000 people (including combatants) have died in Yemen’s war.

Like the UN’s, these statistics only include violent deaths, so they don’t take into account the more than 2,500 Yemenis who died since last April in two waves of cholera, a disease that should be easy to treat.

Yemenis with chronic diseases or other ailments are also likely dying at an elevated rate, uncounted: The World Health Organisation says almost half of Yemen’s health facilities and hospitals have been destroyed as a result of the war, and points out that patients with diagnoses like cancer – the WHO says that’s 35,000, with 11,000 more diagnosed every year – struggle to access treatment.

For its part, Save the Children estimates that 85,000 children may have died of disease and starvation since the conflict escalated in 2015.

More than 2 million displaced

UNHCR, the UN’s agency for refugees, says that more than two million Yemenis are currently internally displaced, meaning they’ve had to flee their homes but remain inside Yemen’s borders.

An estimated 455,000 people have been displaced (some sources put the number as high as 600,000) since a government and coalition offensive began moving up the Red Sea coast in June through Hodeidah province and into the Houthi-held port city of the same name.

Some displaced people are staying with family members, or renting accomodation if they have the money. But many are sheltering in schools or other public buildings, and others are sleeping out in the open or in makeshift shelters.

Leaving home doesn’t just mean the loss of a place to sleep; displaced people are likely to lose their sources of income as well as the local support networks they fall back on in hard times. They are also often at higher risk of contracting diseases like cholera because of poor conditions and difficulty obtaining clean water.

Untold numbers impoverished

Hunger, death, and displacement have been worsened by (and have contributed to) Yemen’s ongoing economic collapse.

While some people – namely those connected with various sides in the fight – are enriching themselves in Yemen’s war economy, most Yemenis are in a downward spiral.

Pretty much every economic indicator for Yemen is dire: while official statistics are no longer available, the World Bank says anecdotal evidence points to a GDP that has contracted by 40 percent since the end of 2014; foreign remittances are down; and Yemen’s currency has been in freefall for months (although it made a slight rebound last month from a record low in October).

Prices of just about everything are up, and the inability to buy food, rather than the lack of it in markets or shops, is a major reason people are going hungry. The UN says fuel prices have doubled in the past two years, and the price of food basics has jumped by 60 percent in the past year.

So, what to expect?

The talks, which are officially called “political consultations”, are unlikely to solve any of these problems right away, or even bring an end to the war.

That’s actually by design: UN envoy Martin Griffiths is first hoping to set the stage for future peace talks, as well as focus on a series of “confidence-building measures”.

On Thursday, he announced that one of these measures, a prisoner swap agreement, had been signed. The deal will be overseen by the International Committee of the Red Cross and Red Crescent (ICRC).

Also on the list: re-opening Sana’a airport to civilian traffic; stabilising Yemen’s economy; and securing a truce in Hodeidah.

The last item is of particular concern to humanitarians, who have long warned that a port closure would bring even further disaster to Yemen, which imports most of its food and has already seen a decrease in commercial ships willing to take the risk of docking at Hodeidah given the recent violence.

Handsome and with neatly slicked hair, Victor Gonzales looks like he belongs more in a boy band than among the dirt-clad miners around El Callao.

Originally from Caracas, the 25-year-old made the journey to the mining town in Bolívar state with his wife five months before IRIN encountered him in August.

“You can’t live in the city anymore; there's no cash, that’s why so many people are coming to the mines. If not, they are leaving the country,” he says. But behind his meek smile, Victor is carrying a daily burden that is preventing him from working each day: malaria.

Alongside Nigeria, South Sudan, and Yemen, Venezuela is one of four countries worldwide that has seen an alarming increase in cases of the mosquito-borne disease.

The World Health Organization raised the alarm in April after a report found that cases of the malaria had jumped 69 percent in 2017 from the previous year. In October, the president of the Venezuelan Medical Federation said the number so far in 2018 was more than 650,000 – if confirmed that would represent an additional 60 percent increase on 2017, with several months still to go.

(Source: WHO, PAHO, Federación Médica de Venezuela)

In the Sifontes municipality, next to El Callao, the towns of Las Claritas and Tumeremo, where illegal mining thrives, have the highest number of reported cases in the country. As far back as 2013, 60 percent of Venezuela’s malaria cases were found in Sifontes.

Last year, the estimate for the whole country was 406,000 cases, five times higher than 2013. Now, hospitals in Caracas, which has long had a very low number of cases, are seeing a rapid increase in patients sick with the disease, and most come from mines in Bolívar state.

“I have already been sick for six days,” says Victor. “Because I sleep in the mine I got infected. This is the fourth time in five months I have had it.”

‘Survival of the fittest’

Away from the scant food shelves and despondent queues seen throughout many of Venezuela’s major cities, El Callao, on the country’s eastern frontier with Guyana, is booming.

“Here in El Callao, thank God, we don’t suffer this crisis; we are blessed with the richness of gold,” says Alberto Garcia, one of the many Venezuelans to have flocked here.

El Callao is Venezuela’s gold capital, and it never sleeps. Gold dealers operate a 24-hour service seven days a week and Garcia is one of them, getting in on the rush. Having arrived two years ago from the city of Valencia, he managed to get connected fast and now works as a buyer. He is one of the lucky ones.

Along the side-street where Garcia works, Syrian, Israeli, and Iranian flags can be seen draped inside shop windows. “People from all over the world are here in El Callao,” says Garcia. “It’s a very profitable place.”

Like Garcia, dealers buy gold from local miners then sell it outside the country. Despite this operation being illegal, the transactions take place in broad daylight in front of the authorities.

But this thriving economy comes at a price: a conflict between the military and local mafias is raging, the mining has brought widespread environmental devastation, and the malaria epidemic is threatening to engulf the entire region. “Here in El Callao,” says Garcia, “it’s survival of the fittest.”

A rapid resurgence

Venezuela was once internationally celebrated for its robust eradication programme. The country waged a vigorous campaign in the 1930s against the virus, which was considered to be endemic.

Led by physician Arnoldo Gabaldón, a nationwide prevention programme using the insecticide DDT was launched throughout the 1940s. By 1955, 10 years after the programme started, the rate was lowered to one per 100,000 people, and in 1961 the WHO declared malaria eradicated from 68 percent of a malaria zone that included two thirds of the country.

Today, it's a different story.

Foreign imposed sanctions are tightening against the government of Nicolás Maduro, who still downplays the severity of the malaria problem. The means to counter the growing epidemic remain slim as money runs out and years of import controls have caused a lack of mosquito nets and other preventative equipment.

After years of wild spending that pumped money into Cuban-style health missions for the poor, the public healthcare system has been neglected for years and is in deep crisis.

Other factors that have helped malaria’s spread include the breakdown of water-pumping systems that increased breeding grounds for mosquitoes, the end of the fumigation programme, and internal migration within Venezuela to affected areas.

Treatment issues

Plasmodium vivax is the most common of the three species of the malaria-carrying parasite that circulate in the area.

Medicine shortages and a lack of prevention programmes have serious consequences for those infected.

Victor wakes up at around 5am to join the queue at the Juan German Hospital. Each day from dawn until dusk the hospital car park fills with families, couples, and single men of all ages, most of them wear their mining boots.

Despite the prospect of free medicine, there is no guarantee a day's wait outside the hospital will get you treatment. Medicine shortages are so acute now that self-treatment options are becoming increasingly common. Children as young as four can be seen among the miners who lie out sick across the tarmac.

Health workers say that even in the smaller clinics they can receive up to 200 new patients daily. Age, a delay in seeking treatment, and self-treatment prior to professional care all affect the number of the parasites in the blood.

Plasmodium vivax is particularly difficult to treat, as it can lie dormant in the liver for months, in some cases years. The medicine Primaquine should be taken for 14 days to treat vivax; but low supplies and unpredictable delivery leave many patients unable to complete the full treatment. Stories of patients in desperate need of cash selling their prescriptions, only to relapse a few weeks later, are also common.

With plasmodium falciparum – the deadliest of the three types of malaria in the area – also prevalent, dozens of people reportedly die each month in El Callao. Obtaining statistics on exact numbers is very difficult due to the reluctance to release reliable data. At Juan German Hospital on one August day, an old Cadillac serving as a mortuary vehicle came and went several times.

A short walk from Juan German Hospital, the medicines needed to treat malaria are easily bought on the black market along with the plastic strips used for the blood smear microscopy examinations.

Primaquine and Chloroquine pills taken from the hospital are sold on the black market for up to two grams of gold on the street corners. Five Venezuelan military personnel guard the hospital doors, but medicines always find a way out.

“Everyone knows who is profiting from the blackmarket trade here, the mafias and the army work together,” says Victor. For miners like Victor who are too sick to work and therefore to pay black market prices, it’s an agonising wait to receive medicine from the hospital.

Despite recent government efforts to dispel the criminal networks that have long reigned in Venezuela´s wildcat mines, little on the ground changes. Military generals lay claim to freshly captured mines and mafias are replaced with new armed groups. An effective response to the malaria epidemic seems to fall behind the long list of priorities in present-day Venezuela.

Maracaibo, the once-opulent heart of Venezuela’s oil industry, now resembles a ghost town.

At the entrance to University Hospital blue rubbish bags are piled high and spill out on the roadway. A dozen black cats prowl, brazenly sniffing at the trash. Neglect has potholed the road; the sprawling modernist building is missing windows and paint is peeling.

Inside, corridors are crammed with broken beds, incubators, lab equipment. The elevators don’t work, the halls are dark. Emigration has halved the nursing staff and reduced the number of doctors by two thirds, employees say. It has also emptied a car park, closed wards, curtailed services, and left parts of the hospital feeling as ghostly and abandoned as the city itself.

“Hospitals,” surgeon and professor Dr. Dora Colomenares says, just before beginning a recent shift, “have become like extermination camps.”

Reliable statistics are impossible to find but, according to a report released in September by Venezuelan human rights group CEPAZ, Venezuela’s public healthcare facilities had by last year lost 60 percent of their 2011 capacity to care for patients. The report cited the dwindling number of trained medical personnel, scarce medicines, and increasingly unreliable basic services due to a lack of water and electricity.

Information Minister Jorge Rodriguez in July announced a “special plan” to address problems within the healthcare system, but he did not provide details then or respond to recent requests for comment from IRIN.

At the same time, long-dormant diseases have re-emerged, given a foothold as widespread malnutrition weakens many Venezuelans’ immune systems, and vaccines and medications become ever scarcer.

Unsurprisingly, morale among the country’s remaining doctors is low. “There is a frustration and sense of impotence,” explains Dr. Rafael Piroza, president of the Association of Medical Doctors in the eastern state of Sucre. “We are formed to give and fight for life, and that we can’t do that makes us feel like accomplices.”

Between 2012 and 2017, 22,000 physicians were registered as leaving Venezuela. While the current number of medical professionals in this country of 32.8 million people is unknown, 39,900 medical personnel were registered as working in Venezuela in 2014, according to the latest figures available from PAHO.

‘Patients are dying’

Official figures on emigration are also hard to come by, but in Maracaibo locals say that as many as 60 percent of the 1.6 million residents who lived here in 2015, according to the most recent UN estimates, have left. That figure sounds impossible until you drive through the empty streets, with shuttered back-to-back home decor shops and high-end auto dealers.

Rubbish flies in the wind in the empty residential neighbourhoods and main streets of this city, in the country’s west. The golden arch of McDonalds is a lone beacon of life for the few cars that pass beneath traffic lights darkened by electricity outages. The occasional person can be seen filling water containers from broken pipes and hauling them home through deserted streets.

Water has become a rarity here and elsewhere in Venezuela. Recent CEPAZ studies reported that 82 percent of the Venezuelan population and 79 percent of hospitals no longer receive water on a regular basis. Electricity is increasingly scarce, too, with frequent outages a feature of life. Large swathes of the country are often left without power, sometimes for days on end.

The impact on daily life is often disastrous, but perhaps nowhere more so than in Venezuela’s hospitals.

Colomenares knows that first hand. Once past the armed security forces guarding the entrance to the University Hospital of Maracaibo, she leans in and, mindful of the security staff that bar journalists from hospitals, confides in a near whisper: “There is no water. Without water, there is bacteria everywhere. It is a vicious cycle – no water, no electricity, no medicines. So it’s like a dead end. Infections, malnutrition – all this leads to a dead end, and death.”

She flings open the doors to a cupboard used to store medicine. Empty. A sink and counter are coated with filth and studded with dead flies.

Since electricity and water services have failed, Colomenares says she has seen deaths in both adults and children “aggressively rise”.

“When I was an intern, if there had been a death – one, two, or three – during my shift, it would have been alarming, very worrying. Now, daily, there are about 20 deaths at this hospital. It is horrendous.”

Dr. Dilmond Antonio, 69 years old, is watching his patients die. His office at the hospital is crammed with medical textbooks and journals, a low-energy light bulb suspended from the ceiling casting a blue-ish light.

Maracaibo hospital was once renowned. It was a pioneer in liver transplants in Venezuela. Antonio says his unit hasn’t done a liver transplant in four years, adding that patients who need them won’t get them: they will die.

Patients who had successful transplants may die, too. A man who had a liver transplant four years ago recently died because he couldn’t find medication to prevent the organ from being rejected, Antonio recalls.

Figures included in the healthcare report released by CEPAZ place Antonio’s patient in the context of a larger story: the man was one of 3,000 organ transplant patients who stopped receiving immunosuppressive drugs this year; one of the 96 who suffered organ rejection; and one of 12 who have already died.

‘Yes, the babies die’

University Hospital of Maracaibo is lucky: it has a generator – at least 33 percent of hospitals nationwide don’t, according to the CEPAZ report. However, due to a lack of maintenance and repair, it often doesn’t work. Even when it does, it can’t supply power to the whole hospital for the erratic and often prolonged blackouts.

On the neonatal ward, a power supply is the difference between life and death. Before the crisis, premature babies born at 29-30 weeks gestation would survive. Now, the survival age has been reduced to 36 weeks gestation, Colomenares says. Almost all born earlier die, she adds.

Lack of functioning incubators means three or four babies will often share one incubator. But when the generator doesn’t work, nothing, including the incubators, works.

"We feel very helpless because there is nothing we can do,” Colomenares says, her voice thickening. “Yes,” she nods, “yes, the babies die.”

Between 2015 and 2016, the infant mortality rate rose by 30 percent and the maternal mortality rate by 66 percent, according to government figures. The health minister behind the release of those figures, Antonieta Caporale, was sacked in May 2017 within days of announcing them.

No more official mortality data has been forthcoming since then, but an October 2018 report from CEPAZ suggests figures “continue to rise into 2018, with the aggravating factors of malnutrition and epidemics”.

“Right now, for us doctors, these [figures] have risen,” Colomenares says. “The conditions are a lot worse now.”

Secretary General of the Organization of American States Luis Almagro Lemes charged in a recent address to the Washington DC-based Center for Strategic Studies that newborns in Syria have a better chance of survival than those born in Venezuela today.

Colomenares’ view of the situation is equally stark. ‘It’s a crime against humanity,” she says.

‘They let him die like a dog’

Isneudy Romero, 27, knows the failings of Venezuela’s medical system. Shifting uneasily as she stands outside the hospital in Maracaibo, she pushes her dark hair off her face, her eyes darting to make sure no one is listening, and begins to speak of her family’s experience.

She’d had a bad summer.

It didn’t begin when she found herself suffocating in the dark after the electricity failure took out the lights, air conditioning, and fridge. It didn’t even start when the city’s water supply failed and she started having to haul water three kilometres from a broken pipe. It started, although she wasn’t to know it quite yet, when Antonio Romero, her 53-year-old father and a long-time government employee, had stomach surgery at the hospital.

The surgery went off without a hitch, so they thought, and he came home. But before long he developed an infection. Romero believes the infection was acquired in the hospital – not unreasonably given that contracting infections in hospitals has become a common occurrence these days due to hospitals having neither water nor cleaning fluid.

Unable to find the antibiotics he needed, her father’s condition worsened. She and her sister took him back to the hospital, where doctors explained he needed a second operation. And then, after a moment’s pause, added apologetically and in pained voices that, regretfully, they were unable to perform the surgery because there was no electricity in the hospital.

That left Romero and her family on a renewed and more desperate quest for antibiotics, hoping they might help keep him alive. But – with the scarcity of drugs rising even higher since a March survey in which more than 88 percent of 100 public and private hospitals and health centres indicated shortages of medication – they hunted high and low in vain. In June, Antonio Romero died.

That wasn’t the end of it.

Coffins are few and far between. When they can be found, they are expensive. Unable to afford the luxuries of a funeral parlour, the family lay their father’s body out on the kitchen table, where they conducted the funeral service, praying the body wouldn’t explode before they managed to raise the money to bury him.

“My father worked 32 years in a ministry – yet they let him die like a dog,” Isneudy Romero says.

Soon after, Romero’s 18-month-old niece fell ill with pneumonia. Five years ago, pneumonia in children in Venezuela was less common, but now severe malnutrition is weakening immune systems and triggering a marked increase in the illness, especially in the under-5’s. Like a growing number of the children in the country, her niece, Luisa, suffered from malnutrition.

Romero and her sister brought Luisa to the hospital, but instead of getting better she contracted a bacterial infection in the intensive care unit.

It was left to the family to supply the material and medicines needed to treat the pneumonia. They constructed an oxygen hood out of pieces of plastic and masking tape. Once again, they tried desperately to find the antibiotics and other medications necessary to treat the infection. Yet again, they looked in vain.

Luisa died from the bacterial infection contracted at the hospital.

Again, a body was placed on the family’s kitchen table.

When all the prayers were said, Luisa was laid in a concrete grave inscribed with hearts drawn by her family’s fingers. The family was left deeply in debt.

‘Of course it is lethal’

Luis Rodriguez, 68, has been to a lot of funerals this year. He worries the next he attends will be his own.

Rodriguez is a former boxer from Cariaco in Sucre State, a small town famed for having produced former super flyweight boxing champion Jesus Rafael Orono.

Today, Rodriguez is a dialysis patient fighting round after round to simply survive – and the bouts are not going his way.

Rodriguez needs three treatments a week, four hours for each treatment, at a clinic in Cumaná, the state capital, about 90 minutes from his home. But with only eight machines of 16 working, his treatments have been reduced by half. And that’s before they were further abbreviated by electricity outages mid-treatment.

The dialysis centre has nothing – no medicine, nothing – so it’s up to Rodriguez to supply the medicines for the treatment and, when he can’t get the required amount of dialysis, hypertension drugs to maintain his health. But hypertension drugs can’t be found anywhere. So, in addition to his kidney problems, he has developed severe hypertension and tachycardia (an abnormally high heart rate).

“Of course, it is lethal,” he says. “Last year there were 65 of us dialysis patients, and, today, there are only 24 of us left.”

Rodriguez falls silent, sitting on a chair amidst the empty stalls in the market where he is passing time. A friend greets Rodriguez, clapping him on the back as he passes by. Rodriguez looks up.

“I have been very pained as a dialysis patient to go to the funerals of my dialysis friends – with no guarantee it will turn out any different for me,” Rodriguez says, shaking this head. “I feel really alone because when I go to dialysis and ask for my friends, they tell me they aren’t here, they have left, either through God or out of the country.”

‘There’s no medicine here’

Some 1,400 kilometres west of Cariaco, the small village of Tucuco sits at the foot of low mountains dense with lush-green foliage and gently shrouded in low clouds.

It is a village like any other in Venezuela these days.

There is a bakery with no bread.

A butcher with no meat.

A bank with no money.

A small hospital without medicines. “Unless there is a mystic there, they are impotent as they don’t have anything to even reduce a fever, or pull a tooth,” one local man confides.

Five years ago, it was paradise here, says Herminia Ramirez, 50. Now, she adds, that paradise has been lost to disease, death, and emigration.

Two families, 14 people in all, live in the Ramirez’s small home of corrugated iron, wood, and thatch.

A small child with carrot-tinged hair characteristic of malnutrition timidly stands in the door of the house, alternating her attention between the chatter outside and the cartoons playing under roll bars on the television indoors. The family’s bright-green pet parrots hop around freely; a pet peccary, or skunk pig, stirs from his sleep and noses at the thin bars of his cage.

Ramirez’s grandfather is swinging, cocooned in a hammock. He is suffering from his fourth bout of malaria this year. Her son is mending his bicycle tyre. He has had malaria nine times, the family says, and now has a colon problem.

“Lots of people we know here have died,” says Ramirez. “Most from malnutrition, but a lot have died of malaria, hepatitis, yellow fever, and tuberculosis too.”

She shrugs. “There’s no medicine here. There’s nothing.”

Dr. Ingrid Graterol nods in agreement. She has been coming here regularly as a doctor with the NGO CARITAS for 15 years and is now the director of the Machiques office.

In Machiques, a two-hour drive from here, there used to be a hospital with a fully equipped operating room, Graterol explains. It no longer functions, so for Martinez’s son to even hope to get treatment for his colon the only option is to get to Maracaibo, 260 kilometres away.

Up to 90 percent of public buses are reportedly out of operation, as bus owners, unable to afford even basic repairs, have been forced to abandon vehicles.

“There is no transport to Maracaibo,” Graterol says. “Now, if a woman needs a C-section, she dies,” she adds by way of explanation. “If she finds a car, there’s no gas. And if she finds gas, maybe the driver wants to sell [their] fuel instead. And, if she finds the car, the gas, and a willing driver, she won’t have the cash.”

A man leading a horse walks slowly by, its hooves clattering on the pavement, interrupting a moment of silence. Graterol continues, anger in her voice, explaining how there used to be no deaths from childbirth in the region.

“If we had one, that would be really bad and they’d call for an investigation,” she says. “Now, we have almost one a month. And it’s not even important anymore as it happens so much no one cares.”

‘I feel depressed’

As hospital conditions worsen and more facilities close, more and more medical personnel are leaving the country.

“I feel depressed, it pains me badly when, as president of the association, I have to sign legal papers to enable doctors to emigrate,” explains Piroza of the Association of Medical Doctors. “I feel a great pain – but I understand their situation, as salaries are too small even for them to eat, and they will be very welcome where they go.”

The doctors who remain have not stopped fighting for their patients.

Protests by medical personnel and people affected by the failures of the healthcare system are on the rise. According to the Venezuelan Observatory of Social Conflict, a local human rights NGO, between January and August 296 protests were held despite the very real risk of protesting: doctors have been threatened with criminal charges for speaking out and hospital directors have been suspended.

Piroza himself took part in a recent protest by medical staff at a small hospital in Cumaná. He and his colleagues covered a fence with large cardboard signs detailing what they don’t have in their facility: oxygen, supplies for carrying out basic tests, drugs, water, light bulbs. In short, everything.

One of a series of stories from within Venezuela, reporting on the humanitarian impacts of the country's economic collapse. <a href="https://www.irinnews.org/special-report/2018/11/20/venezuela-humanitarian-crisis-denied">Read more here</a>.

IRIN editors give their weekly take on humanitarian news, trends, and developments from around the globe.

On our radar

COP24 opens with stark warnings

The UN climate change conference, COP24, begins 2 December in Poland, and vulnerable countries and aid groups are paying particularly close attention. Negotiators are under pressure to hammer out the so-called “rulebook” that lays the ground rules for implementing the Paris Agreement. The 2015 accord outlined broad commitments for tackling climate change – limiting temperature rise, financing to help lower-income countries, developing national climate strategies – but now negotiators must agree on how to make it all work. Nations most susceptible to climate change will be looking for consensus on limiting global temperature rise to 1.5 degrees Celsius, and for more concrete commitments to climate funding – Vanuatu’s foreign minister has pledged to “optimistically but aggressively” engage at COP24, challenging climate polluters and urging progress on the divisive issue of “loss and damage” compensation to vulnerable nations. Humanitarian groups are increasingly witnessing the effects of climate change in everyday aid response. Oxfam says governments at COP24 face “life and death” decisions. For more, read our reporting on the humanitarian impacts of climate change.

Upsurge in Boko Haram attacks

A spike in jihadist attacks against military and civilian targets in northeastern Nigeria is undermining claims that Boko Haram has been "defeated". Around 100 Nigerian soldiers were reportedly killed in an attack on an army base earlier this month by Islamic State West Africa Province, a Boko Haram splinter group. AFP has reported at least 17 attempts to overrun army bases in the region since July. Speaking this week in Maiduguri, the birthplace of the insurgency, Nigerian President Muhammadu Buhari said defeating Boko Haram was "a must-win war”, adding: "Our troops must not be distracted. They should be committed to the task of eliminating Boko Haram from the face of the Earth.” During the nine-year rebellion, more than 27,000 people have been killed and 1.8 million displaced. Read more of IRIN’s in-depth coverage: Countering militancy in the Sahel.

Fake humanitarians in Gaza?

Remember that mid-November flare-up of violence in Gaza, said to be the worst since 2014 and eventually paused by an Egypt-brokered ceasefire? It all began with a botched Israeli operation in the Palestinian enclave, and reports in the Israelimedia recently emerged (based in part on information from Hamas and limited by Israel’s official military censor) that soldiers may have been posing as Palestinian aid workers, having entered the strip with forged documents. We can’t (for now) independently confirm these reports, but it’s worth noting that with Gaza’s economy in steady decline, the UN’s agency for Palestine refugees, UNRWA, says 80 percent of the area’s 1.9 million residents depend on aid to get by. Just this week, the medical charity Médecins Sans Frontières said a “slow-motion healthcare emergency is unfolding” in Gaza as the healthcare system is overwhelmed by the number of patients shot or injured by the Israeli army during ongoing protests.

'Sex-for-jobs’ scandal hits AU

An internal investigation by the African Union has uncovered a de facto system whereby "young women are exploited for sex in exchange for jobs”. The findings, made public last week, found widespread reports of mistreatment, and said sexual harassment in particular was confirmed by all 88 women interviewed as part of the probe; youth volunteers and interns were found to be most vulnerable. The inquiry into harassment and gender discrimination was launched in May after three dozen women made allegations about what they called “professional apartheid against female employees in the commission”. In response to the findings, the continental body will establish a comprehensive sexual harassment policy – something that did not previously exist. Although the AU has made ‘women, gender and development’ a key part of its external priorities, internally, more needs to be done to protect victims and ensure perpetrators are called to account. Read more of IRIN’s in-depth coverage on #MeToo in the aid sector.

Women in disaster response

Women face greater risks during and after disasters, but they’re often overlooked when it comes to participating in humanitarian responses – despite sector-wide commitments to boost the role of women and girls during crises. New research by CARE International, released during the ongoing 16 days of activism against gender-based violence campaign, examines what’s preventing more women responders from being included, and outlines potential solutions to the problem. Social norms and discrimination may be obvious barriers to participation, but aid groups and donors must also do more to ensure women take part, the report states. Sidelining women isn’t simply unjust – it’s also a “significant missed opportunity” to make responses better, it notes. Read the research here.

In case you missed it

Afghanistan: President Ashraf Ghani this week announced the formation of a 12-person negotiation team aimed at striking a peace agreement with the Taliban. But it’s unclear whether the militant group is open to direct negotiations with the government, which has not been involved in separate preliminary discussions between Taliban and US officials.

Afghanistan: At least 23 civilians were killed in an airstrike in southern Helmand Province on 27 November, according to the UN mission. The US military said it is investigating. The UN says the number of civilian deaths caused by airstrikes this year – 649 through the end of September – is the highest in nearly a decade.

Iraq: Heavy rains last weekend caused severe flooding, displacing thousands as tents were wiped out, homes destroyed, and an unknown number of people killed.

Measles: In 2017, cases of measles increased 6,358 percent in the Americas (fuelled by an outbreak in Venezuela) and 458 percent in Europe (driven by “falsehoods” about the vaccine), according to a new study and press release from leading health agencies warning that the disease is in a “resurgence”.

Vanuatu: The government of the Pacific nation is telling residents of Ambae to stay away from the island, which was completely evacuated in July due to an erupting volcano. It’s unclear when – or if – the estimated 9,000 or more residents will be allowed to return.

Yemen: The US Senate voted on Wednesday to move forward with debate on a measure that would (if it succeeds, and that’s a big if) end American military support for the Saudi Arabia-led coalition fighting in Yemen.

Coming up

In Geneva on 4 December, the UN will appeal for humanitarian funding in 2019. The UN agencies, along with governments and many NGOs, put together annual plans to respond to the most urgent emergency situations. This year the Global Humanitarian Overview sought about $25 billion, to help 97 million people, and so far got about $14 billion. Donors are finding more to give, but needs keep rising. Things to watch: How big will Yemen's appeal need to get to ward off famine? Which countries will no longer need an appeal? Which will join the sorry ranks of the world's top crises? These giant funding appeals don't include all international efforts, by the way: the Red Cross and Red Crescent Movement and MSF, for example, operate independently. While we’re digesting that, on 5 December, a beefy 330-page report lands, reviewing the sector over the last three years. ALNAP's sweeping State of the Humanitarian System publication is based on literature reviews, evaluations, original case studies, hundreds of interviews, surveys of recipients of aid and data analysis.

Our weekend read

Exposed: UNHCR's role in Uganda refugee aid scandal

What do 15,000 solar lamps, 50,000 wheelbarrows, and 288,000 blankets have in common? It’s not a joke. Unbelievably, they are just part of the litany of waste the UN’s refugee agency, UNHCR, presided over in Uganda, where hundreds of thousands of civilians fled war and hunger in South Sudan needing every bit of help they could get. In February, when the scandal first broke, it was Ugandan officials in the firing line over a string of offences ranging from theft of relief items to appropriating land meant for refugees. Now, as IRIN Senior Editor Ben Parker lays bare in our weekend read, it is very much UNHCR. An explosive audit by the UN’s Office of Internal Oversight Services reveals a catalogue of errors and mismanagement totalling tens of millions of dollars. How and why could this happen? For clues, look at the vertiginous extent to which Uganda was being held up – during a period of rising xenophobia globally – as a model refugee-hosting nation. “Does that influence the oversight and dissuade UNHCR from digging a little deeper and uncovering corruption and mismanagement? Who has leverage on who?” asks one humanitarian insider.

And finally…

"They think I'm different"

A 15-year-old boy is shoved to the ground by a bigger youth, who with one hand on his throat pours water on his face saying: "I'll drown you". A viral video of a sports pitch incident in northern England has led to police charges for the bully and an outpouring of help. In a TV interview, the boy, whose family are refugees resettled from Syria in 2016, said he and his sister had put up with a barrage of bullying and name-calling at school. "When I came to the UK, I felt I was going to be safe,” he said. While the school, police, and local authorities are facing questions over their handling of the case, a crowdfunding campaign has quickly raised about £150,000 ($190,000) to support the family.

Taking stock in Afghanistan

There are plenty of humanitarian issues in Afghanistan: soaring civilian casualties and mass displacement caused by conflict; drought-parched land; the yearly return of hundreds of thousands of refugees and undocumented migrants pushed out of neighbouring countries. These and other critical topics will be on the table as Afghanistan’s leaders meet with international donors, senior aid officials, civil society groups, and humanitarian and development experts at a UN-hosted conference in Geneva on 27 and 28 November. Organisers say it’s a “crucial moment” for both the government itself and the international community. The government will be looking to bolster international support; donors will be measuring progress on some of the billions in funding promised to the country. Presidential elections are scheduled for April, but the country is mired in an increasingly complex war and progress on possible peace talks with the Taliban has been elusive.

Preparing for El Niño

The Food and Agriculture Organization is urging early action to prepare for the impacts of a possible El Niño event in the coming months. Global El Niño weather phenomena, which are linked to a cycle of warming ocean temperatures in the Pacific, sharpen the risk of extreme weather in volatile ways: heavy rains and flooding in some areas; severe drought in others. Countries already dealing with humanitarian crises could be among those most at risk. An FAO bulletin released this week cites nations from Venezuela and Colombia, to DRC and Malawi, to the Philippines, Papua New Guinea, and Vanuatu as being at risk of rainfall shortages. In turn, countries like Somalia, Kenya, Pakistan, and Afghanistan could see excess rains. Parts of Kiribati in the Pacific could see both wet and dry conditions. The FAO says it’s important that policymakers and planners realise that El Niño’s impacts “can be mitigated before they generate large-scale food security emergencies”. The risks can be steep: the last severe El Niño in 2015 and 2016 triggered appeals for international humanitarian aid in 23 countries, totalling more than $5 billion, the FAO notes.

Climate vulnerable but fighting back

The Pacific island nation of Vanuatu intends to challenge the big polluters it holds responsible for costly climate-linked destruction on its soil. Vanuatu’s foreign affairs minister, Ralph Regenvanu, said the country will explore taking legal action against the fossil fuel industry – as well as governments that profit from it – as part of a movement to “shift the costs of climate protection” back onto those most responsible for climate change. Regenvanu made his comments on Thursday at a virtual climate summit staged by the Climate Vulnerable Forum – a group of nearly 50 developing countries pushing for the world to take stronger action on climate change. The CVF summit is intended to galvanise international efforts to limit global warming to 1.5 degrees Celsius ahead of this year’s iteration of the annual UN climate conference, COP24, slated for December in Poland. But smaller countries – which are some of the most vulnerable to climate change’s impacts but often have the least to do with its causes – are also growing increasingly frustrated about global commitments to address monetary damages caused by climate-linked disasters. Regenvanu said Vanuatu lost nearly two thirds of its GDP from a single tropical storm – Cyclone Pam in 2015. “The climate loss and damages ravaging Vanuatu will not go unchallenged,” Regenvanu said.

In case you missed it

AFGHANISTAN: Attacks on religious targets continue to claim lives. An explosion killed at least 26 people attending Friday prayers at a mosque in eastern Afghanistan on 23 November, while a 20 November suicide blast at a gathering of religious scholars in Kabul killed at least 50 and injured dozens more.

AFGHANISTAN: Drought is adding to the continuing humanitarian emergency in Afghanistan, but it's also bad for the opium business. According to figures released by the United Nations Office on Drugs and Crime this week, the estimated land area used for opium cultivation this year has fallen by one fifth since 2017’s record high – partly due to severe drought impacts in western Afghanistan.

MALARIA: No significant progress was made to reduce global malaria cases between 2015 and 2017, according to a new report by the World Health Organization, which said that the pace of fighting the disease has stalled. An estimated 219 million malaria cases were reported in 2017, and the disease still kills more than 435,000 people annually, mainly in Africa. Meanwhile, in a separate effort to try and reduce transmission, thousands of genetically modified mosquitoes are set to be released in a village in Burkina Faso as part of a project aimed at wiping out the malaria-carrying insects. Not everyone is convinced.

One to listen to

‘Number One Ladies’ Landmine Agency’

At the northwestern corner of the African continent lies one of the world’s least reported but longest-running conflicts – Western Sahara. At the heart of it are the region’s Sahrawi people. In this BBC radio documentary, we get a peek into the lives of a unique band of frontline workers: the self-appointed ‘Number One Ladies’ Landmine Agency’, a collective of local women working to clear unexploded bombs along the world’s longest (2,700-kilometre) minefield. Operating in temperatures exceeding 42 degrees Celsius, and at least four hours away from the nearest hospital, they risk their lives and limbs ridding the so-called “Liberated Territories” of some of the seven million mines left over from the unresolved conflict between Morocco and a Sahrawi liberation movement called the Polisario Front. While the group of mostly young women are committed to their part in making their home region safer, they also forge ahead socially – challenging cultural and religious stereotypes, and pushing boundaries to rewrite the role of women in their traditional community. But the team also faces significant challenges: living in Africa’s last-remaining colony as refugees; working in a physically and politically hostile environment; and knowing that an accident is only a footstep away.

Our weekend read

Venezuela has the largest proven oil reserves in the world and yet, despite suffering no conflict, its people have been fleeing on a scale and at a rate comparable in recent memory only to Syrians at the height of the civil war and the Rohingya from Myanmar.

Millions have escaped the economic meltdown since 2015 and started afresh in countries like Brazil, Colombia, Ecuador, and Peru. But what of the many millions more who remain in Venezuela? Regular IRIN contributor Susan Schulman spent weeks covering 1,400 kilometres from Carupano in the east to Tucuco in the far west to seek answers. Take time this weekend to read the latest instalment of her ongoing multimedia series. The government of President Nicolás Maduro insists there is no humanitarian crisis, but find out the hungry reality of the "Maduro diet", how ordinary people have taken to hijacking lorries for food and stashing their supplies in graves to survive.

And finally…

Emergency emojis

Notorious for its acronyms, jargon, and lengthy documents, some would argue the international aid sector needs all the help it can get in non-verbal communication. Flood, fire, volcano, earthquake: some disaster events are easy enough to condense down to a monochrome icon. In 2012, graphic designers at the UN’s emergency aid coordination body, OCHA, released into the public domain about 500 graphical icons that can be used in emergency-related reports, maps, and infographics. They include, for example, a wilted plant to symbolise drought, and a fax machine. Other concepts in the humanitarian world are not the easiest to communicate in a tiny black-and-white visual. How would you draw "harassment", "submersible pump", or "rural exodus"? In a new release, OCHA has updated some of the icons (even tweaking the trusty old fax machine) and added new ones. Some are depressing signs of the times: "roadblock", "burned house", and "sexual violence". Other novelties show changes in the humanitarian work environment: "cash transfer" , "reconstruction", and "cell-tower". You can pick up the icons hosted at the Noun Project here. We can only salute the graphic designer who was given the task of making "gap analysis", "humanitarian programme cycle", and "multi-cluster-multi-sector" into universally-understandable symbols.